The Obama administration will bend Medicaid to woo Republican governors into Obamacare's expansion — but they're not going to break it.
That was the takeaway from the announcement Thursday that the White House had struck a deal with Pennsylvania to move forward on the Obamacare program, which will cover an estimated 300,000 Pennsylvanians.
Republican governors have used the Medicaid expansion as a moment of leverage, to ask the Obama administration to agree to conservative Medicaid reforms they might not otherwise consider. Many have used the opportunity to make the public program look more like private insurance, with more choice of plans and monthly premiums.
"The administration is working very hard to come to agreement with Republican governors where they can," says Tevi Troy, president of the American Health Policy Institute and a former Health and Human Services official in the Bush administration. "Because they want people to sign up for the expansion...they're working pretty hard to make compromises."
And generally they've been successful — up until Pennsylvania Gov. Tom Corbett. He proposed tying Medicaid eligibility to employment, requiring enrollees to either be working or actively job searching.
Republicans and Obama are working together on Obamacare. Seriously.
Since the Supreme Court made the Medicaid expansion optional in 2012, states that oppose Obamacare have used the moment to ask the Obama administration for waivers that allow them more flexibility in how they run their Medicaid programs.
These agreements give states permission to make changes to Medicaid that aren't otherwise allowed, like changing the benefits patients receive or allowing a private company to run their health coverage rather than the state.
Six governors — five Republicans and one Democratic, including Corbett — have petitioned the White House for waivers. A seventh, Tennessee Gov. Bill Haslam, announced he may do so later this month.
Arkansas and Iowa have pursued Medicaid expansions that enroll patients into private health insurance, with premiums paid by public dollars. This flexibility did exist prior to Obamacare, but states had barely used the option until conservative states were looking for more palatable ways to grow an entitlement program.
Not everything is on the table